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Title IX: Sexual Harassment, Sexual Assault, Domestic Violence, and Stalking Reporting Form


TO REPORT AN EMERGENCY OR IF YOU ARE REPORTING AN INCIDENT THAT POSES AN IMMINENT RISK OF HARM TO A PERSON(S) OR PROPERTY CALL UNIVERSITY POLICE AT 620-235-4624 OR DIAL 911 FROM ANY CAMPUS OR CELL PHONE BEFORE COMPLETING THIS FORM.

This form should be used to report concerns pertaining to possible violations of the Pittsburg State University Sexual Harassment Policy such as dating violence, domestic violence, sexual assault, sexual harassment, stalking, or other forms of sexual misconduct. The Pittsburg State University Sexual Misconduct Policy can be found at https://www.pittstate.edu/office/title-ix/index.html

Pittsburg State University respects the sensitivity of the information that may be included in this form. Filing this incident report only notifies Pittsburg State University's Title IX Coordinator, Jamie Thayer. Please note that as mandated by Title IX as a federal law, the information included in this form is not confidential, but will be kept as private as possible in all efforts to protect individuals and the greater university community.

Completing this report does not substitute filing a report with University Police or Pittsburg Police Department. To file a report with University Police, please dial 911, call 620-235-4624 or go to University Police which is located on the ground floor of Shirk Hall. University Police can assist in privately contacting local Police.

If you are unsure or would like to speak to someone about completing this report form, please call the Title IX Coordinator at 620-235-4189.


Background Information

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Involved Parties

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Incident Overview

Please provide as many details regarding the incident, including what you observed, the locations of witnesses and any other information that could be valuable in the investigatory process.

Basis of Complaint: (select all applicable options)(Required)
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What was your relationship with the alleged (respondent) at the time of the incident?(Required)
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Please indicate other departments who have been notified of this incident:(Required)
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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
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